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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157209068
Report Date: 11/20/2024
Date Signed: 11/20/2024 05:59:29 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/13/2024 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20240913133620
FACILITY NAME:HIGH DESERT HAVENFACILITY NUMBER:
157209068
ADMINISTRATOR:MATHEW, ABRAHAMFACILITY TYPE:
740
ADDRESS:1240 COLLEGE HEIGHTS BLVDTELEPHONE:
(760) 371-1989
CITY:RIDGECRESTSTATE: CAZIP CODE:
93555
CAPACITY:82CENSUS: 74DATE:
11/20/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Care Coordinator Lena Pokol TIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility staff do not keep the facility clean or sanitary
Facility staff increased resident rent beyond the allowed SSI/SSP amount
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Shawna Doucette and Brianna Miranda conducted a visit to commence a complaint investigation. LPA's identified themselves and discussed the purpose of the visit and the elements of the allegations with Care Coordinator Lena Pokol. LPA contacted Administrator via telephone who gave persmission for Care Coordinator to sign for this report.

Based on records review and interviews, R1 is on SSI and received a letter stating facility is raising the rent. LPA reviewed R1's admissions agreement, which states R1 pays $3731.77. LPA's interviewed R2 who is also on SSI and R2 recieved a letter from the facility to raise the rent. LPA obtained copies of letters sent out by facility.

Based on tour of the facility, staff do not keep facility clean or sanitary. R1's carpet was dirty and trash was found outside in an open trash bag next to the dining door. Facility was cited during the annual inspection on 10/09/24 and 10/10/24.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/13/2024 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20240913133620

FACILITY NAME:HIGH DESERT HAVENFACILITY NUMBER:
157209068
ADMINISTRATOR:MATHEW, ABRAHAMFACILITY TYPE:
740
ADDRESS:1240 COLLEGE HEIGHTS BLVDTELEPHONE:
(760) 371-1989
CITY:RIDGECRESTSTATE: CAZIP CODE:
93555
CAPACITY:82CENSUS: DATE:
11/20/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Care Coordinator Lena TIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff do not ensure resident's wifi is working
Facility staff did not keep the facility free from strong perfume smells
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Shawna Doucette and Brianna Miranda conducted a visit to commence a complaint investigation. LPA's identified themselves and discussed the purpose of the visit and the elements of the allegations with Care Coordinator Lena Pokol. LPA contacted Administrator via telephone who gave persmission for Care Coordinator to sign for this report.

LPA obtained a copy of a bill for internet service.

Based on interviews, facility has wifi however in certain areas the wifi sometimes have a poor connection. Based on record review, Facility uses Frontier for wifi service.

Based on tour of the facility, LPA did not smell any strong perfume smells. Based on interviews, it is unknown if there was a time the facility
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 24-AS-20240913133620
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: HIGH DESERT HAVEN
FACILITY NUMBER: 157209068
VISIT DATE: 11/20/2024
NARRATIVE
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Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 24-AS-20240913133620
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: HIGH DESERT HAVEN
FACILITY NUMBER: 157209068
VISIT DATE: 11/20/2024
NARRATIVE
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Based on record review and interviews, the preponderance of evidence standard has been met; therefore, the above allegation is found to be Substantiated. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D.

An exit interview was conducted and a copy of this report along with appeal rights and plan of correction were provided.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 24-AS-20240913133620
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: HIGH DESERT HAVEN
FACILITY NUMBER: 157209068
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/22/2024
Section Cited
HSC
1569.655(c)
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(c) If a licensee increases rates for a recipient under the State Supplementary Program for the Aged, Blind and Disabled, described in Article 5 (Commencing with Section 12200) of Chapter 3 of Part 3 of Division 9 of the
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Licensee agrees to submit a written statement showing an understanding of this regulation and a copy of a corrected admissions agreement for R1 by POC due date 11/22/24,
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Welfare and Institutions Code, the licensee shall meet the requirements for SSI/SSP rate increases, as prescribed by law. This requirement was not as evidenced by Licensee sent out letters of a rate increase for SSI residents R1 and R2. R1's admissions agreement states R1 pays $3731.77 which poses a potential health safety and or personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5